Healthcare Provider Details

I. General information

NPI: 1962473314
Provider Name (Legal Business Name): LIONEL G BERCOVITCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET, APC-10
PROVIDENCE RI
02903
US

IV. Provider business mailing address

593 EDDY STREET, APC-10
PROVIDENCE RI
02903
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-7959
  • Fax: 401-444-7144
Mailing address:
  • Phone: 401-444-7959
  • Fax: 401-444-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number36392
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD05283
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: